One hospital was fined because it had shower knobs that allowed a teenage girl to hang herself.

Another got into hot water after doctors left a piece of tubing inside a heart-surgery patient.

And a third was cited for basically allowing a patient to eat herself to death.

They were among the 14 facilities, four of them in the Bay Area, that were fined by the California Department of Public Health this week following investigations that revealed their employees were somehow responsible for a patient’s serious injury or death.

The incidents, which took place from 2012 to 2016, resulted in a combined $1.1 million in fines levied against the hospitals. Here are some of the more egregious examples of how the hospitals screwed up:

Aurora Vista Del Mar, Ventura

Investigators say the hospital failed to provide a safe environment for patients after a suicidal 17-year-old girl hanged herself, using bed linen tied to a knob in the shower. Citing Health and Safety Code Section 1280.3 (g), the report accuses the facility of creating “immediate jeopardy,” which is defined as “a situation in which the licensee’s noncompliance with one or more requirements of licensure has caused, or is likely to cause, serious injury or death to the patient.” Running a hospital with shower knobs that can be used to assist in a suicide creates such a jeopardy.

The penalty: $75,000

Sequoia Hospital, Redwood City

In a word, this is what Sequoia was fined for: Oophorectomy

Pronounced oh-of-uh-REK-tuh-me, it means “surgical removal of the ovaries,” and investigators say the facility’s doctors did just that, which would have been fine if that’s what the patient had ordered. During the February 2016 surgery, doctors were supposed to remove the unidentified patient’s uterus, fallopian tubes and appendix, but instead took out her ovaries, according to the report. It was not clear whether the doctors also removed the things they were supposed to have removed.

The penalty: $47,450

Sutter Davis Hospital, Davis

For this facility, the “adverse event” that led to the fine was: “Retention of a foreign object in a patient after surgery or other procedure.” During the operation in early 2012, a “central venous catheter segment (piece of small tubing threaded into a large chest vein for delivery of
medications and fluids) broke away.” The 6.3-inch piece of tubing “was left inside Patient 1 with no post-operative attempt made to extract it.” The patient later developed a blood clot in her lung which doctors determined was triggered by the wayward catheter. Another surgery followed to remove the tube. In interviews with members of the surgical team, investigators discovered that “surgery staff was aware a piece of IV tubing had remained inside Patient 1 after the procedure,” but that it “never got reported” at the time.

The penalty: $50,000

Santa Barbara Cottage Hospital, Santa Barbara

Investigators reported that the facility’s staff had failed to properly care for a 71-year-old man while in the ICU following a surgery in early 2015. Though he was clearly a fall risk, a bed alarm was not turned on and the patient fell, essentially, to his death: Nurses found him on the floor in a pool of blood and six days later he was dead.

The penalty: $75,000

Bakersfield Memorial Hospital, Bakersfield

Even though the recovering brain-surgery patient was known to suffer from a food-and-swallowing disorder that caused her to shove food into her mouth at a dangerously fast clip, staffers failed to get her the soft-food meals ordered by her doctors. “Continues to eat without chewing well and tends to choke,” a physical therapist wrote in a report. “She continues to shovel food into [her] mouth quickly and without chewing and swallowing at regular intervals and continues to choke.”

In late March of 2016, the patient stuffed so much food into her mouth that she went into cardiac arrest, causing her heart to stop beating for 13 minutes. Doctors tried to save her, but they had trouble dislodging everything she’d crammed into her mouth. The report said the food pieces were “just too big to be sucked out” and a doctor had to use a pair of forceps to remove the food matter so they could insert an intubation tube. She was eventually pronounced brain dead.

Patrick May is an award-winning writer for the Bay Area News Group working with the business desk as a general assignment reporter. Over his 34 years in daily newspapers, he has traveled overseas and around the nation, covering wars and natural disasters, writing both breaking news stories and human-interest features. He has won numerous national and regional writing awards during his years as a reporter, 17 of them spent at the Miami Herald.

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